Hashim Clinical Log 3
Hashim Clinical Log 3
Hashim Clinical Log 3
Date: 23/11/2022 Site: CICU Preceptor: Dr. Jihad & Dr. Anas
Therapeutic Nursing
Age/Sex Diagnosis Pertinent Assessment Findings Interventions
61 male DX: The HX: Nursing Diagnosis:
decreased Medical Hx: IHD, last 1.Impaired Gas Exchange
level of cath in 2013, 7 stents. related to Altered oxygen
consciousness History of recent COPD supply (obstruction of
and COPD and DM diagnosis airways by secretions,
Recently COPD bronchospasm; air-
CC: patient exacerbation admission to trapping), Alveoli
said” I have ICU in prince rashed destruction, Alveolar-
had difficulty hospital, discharged 10 capillary membrane
breathing and days ago. changes evidenced by
feeling of Heavy smoker 2 packs changes in ABGS,
dizziness for daily hypercapnia, CTA report,
2 days ” no previous surgeries, no change in vital signs o2
known drug or food sat less than 92% .
allergies
HPI:
The patient was admitted Desired Outcomes
according to his family when they
noticed his decreased level of The client will
consciousness, increased dry demonstrate improved
cough, and shortness of breath, ventilation and adequate
his blood pressure was found oxygenation of tissues by
80/50, and his status of bedridden ABGs within the
was since 1 month. Co2 was patient’s normal range
found 102 patient with co2 and be free of symptoms
retention so the patient was put on of respiratory distress.
BiPAP in ER and transferred to
ICU department.
2. impaired physical
Abnormal Labs results: mobility related to
WBC 12.2 increased. 4-9 Imbalanced between
H.B 8 g/d decreased 13-16 oxygen supply and
HCT 23.6 decreased 35-45 demand due to inefficient
Plt 410 high 150-400 work of breathing,
anemia and disease
- Creatinine 25.9umol/l low (62- process evidenced by
115) patient status of
- calcium 2.3 low mmol/l 2.2- bedridden.
2.7
- PCO2 59 high 35-45
respiratory acidosis
HCO3 38 high 22-26 Desired outcomes:
5.Monitor O2 saturation
and titrate oxygen to
maintain Sp02 between
88% to 92%.
6.Monitor arterial
blood gas values as
ordered.
8.Encourage
expectoration of
sputum; suction when
needed.
10Encourage deep-slow
or pursed-lip breathing
as individually needed
or tolerated.
12.Administering
humidified oxygen
prevents drying out the
airways, decreases
convective moisture
losses, and improves
compliance.
24.Monitor site of
impaired tissue integrity
at least once daily for
color changes, redness,
swelling, warmth, pain,
or other signs of infection
26.Assess patient’s
nutritional status; refer
for a nutritional
consultation or institute
dietary supplements.
Inadequate nutritional
intake places the patient
at risk for skin
breakdown and
compromises healing,
causing impaired tissue
integrity.
References
Beaumont, M., Forget, P., Couturaud, F., & Reychler, G. (2018). Effects of inspiratory muscle